Transcatheter Aortic Valve Replacement in a Patient With Pre-existing Left Ventricular Pseudoaneurysm: The Importance of Pre- and Intra-procedural Imaging

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An 85-year-old man with a history of myocardial infarction and coronary bypass surgery presented with severe symptomatic aortic stenosis. Echocardiography revealed pressure gradients of 73/40 mm Hg across the aortic valve, an aortic valve area of 0.74 cm², and a 35% ejection fraction. The left ventricular (LV) posterior wall was akinetic, with a large lateral wall pseudoaneurysm. Computed tomography angiography confirmed a large basal lateral left ventricular (LV) pseudoaneurysm (4.9 x 4.7 x 4.5 cm) (Figure 1A and B). The patient was at high risk for surgical valve replacement and was referred for a transcatheter aortic valve replacement (TAVR). We were concerned that inadvertent insertion of a stiff guidewire into the pseudoaneurysm during TAVR would cause cardiac rupture.

TAVR was performed under general anesthesia with transesophageal echocardiography (TEE) guidance. Initial positioning of a straight-tip guidewire within the pseudoaneurysm (Figure 1C) was detected by TEE and the wire was repositioned to the LV apex (Figure 1D). A stiff pre-shaped guidewire (Confida, Medtronic) was then positioned within the LV apex (Figure 1E) and direct implantation of a 26-mm Sapien 3 valve (Edwards) was performed successfully (Figure 1F). The patient recovered uneventfully. This case emphasizes the importance of multi-modality pre- and intra-procedural imaging during TAVR.

Affiliations and Disclosures

From the Department of Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: The patient gave written informed consent for performing the procedure. Verbal informed consent was given by the patient to present the procedural details anonymously.

Address for correspondence: Ronen Jaffe, MD, Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 7 Michal St, Haifa 34362, Israel. Email: jaffe@clalit.org.il